A nurse is preparing to suction secretions from a patient who has a new tracheostomy. Which of the following actions should the nurse plan to take?

Use a resuscitation bag with 80% oxygen prior to the procedure.

Select a suction catheter that is half the size of the lumen.

Place the end of the suction catheter in water-soluble lubricant.

Adjust the wall suction apparatus to a pressure of 170 mm Hg.

Answer and Explanation

The Correct Answer is B

Choice A rationale: Using a resuscitation bag with 80% oxygen prior to the procedure is inappropriate. While pre-oxygenation is important before suctioning to prevent hypoxia, the oxygen concentration should be 100%, not 80%. Normal oxygen saturation levels are 95% to 100%. Pre-oxygenating with 100% oxygen ensures the patient maintains adequate oxygenation during the brief suctioning period. Using 80% oxygen does not fully optimize oxygen reserves for this purpose.

Choice B rationale: Selecting a suction catheter that is half the size of the tracheostomy lumen is appropriate. This size prevents excessive occlusion of the airway, ensuring adequate airflow during suctioning. The correct catheter size minimizes trauma to the tracheal mucosa and prevents hypoxia. The catheter should not exceed 50% of the tracheostomy diameter to maintain proper airway function, making this the correct action for safe and effective suctioning.

Choice C rationale

Placing the end of the suction catheter in water-soluble lubricant is not recommended. This could introduce bacteria into the airway and increase the risk of infection.

Choice D rationale

Adjusting the wall suction apparatus to a pressure of 170 mm Hg is not correct. The recommended suction pressure for adults is usually between 80 and 120 mm Hg. Suctioning at too high a pressure can cause trauma to the airway.

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Correct Answer is A

Explanation

Choice A rationale

The first action the nurse should take when finding a patient on the floor is to check the patient for injuries. This is important to determine the extent of any potential harm and to guide subsequent actions.

Choice B rationale

Moving hazardous objects away from the patient is important, but it is not the first action the nurse should take. The nurse should first assess the patient for injuries.

Choice C rationale

Notifying the provider is an important step when a patient falls, but it is not the first action the nurse should take. The nurse should first assess the patient for injuries.

Choice D rationale

Asking the patient to describe how they felt prior to the fall is part of the assessment after a fall, but it is not the first action the nurse should take. The nurse should first assess the patient for injuries.

A. Walking briskly B. Riding a bicycle C. Performing isometric exercises D. Engaging in high-impact aerobics

Correct Answer is A

Explanation

Choice A rationale

Walking briskly is a weight-bearing exercise that is essential for maintaining bone mass, which can help to prevent osteoporosis. Regular weight-bearing exercise, such as a 20-30-minute aerobic exercise, 3 times a week, is recommended for older adults at risk for osteoporosis.

Choice B rationale

Riding a bicycle is a non-weight-bearing exercise. While it can contribute to overall fitness and health, it does not provide the same benefits for bone health as weight-bearing exercises like walking.

Choice C rationale

Performing isometric exercises can help to strengthen muscles, but these exercises do not have the same impact on bone health as weight-bearing exercises.

Choice D rationale

Engaging in high-impact aerobics can be beneficial for bone health, but it may not be suitable for an older adult at risk for osteoporosis due to the increased risk of injury.

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